HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM

DATE: _____________ Temperature: ______ DATE: _____________ Temperature: _________ DATE: _____________ Temperature: ___________
Time In: ___________ Time Out: _________ Time In: ________ Time Out: ____________ Time In: ________ Time Out: _______________
_ NAME______________________SEX: ____AGE: ___ _ NAME________________________SEX: _____AGE: ______ _ NAME______________________________SEX: ____AGE: _______
RESIDENCE: _________________________________ RESIDENCE: ______________________________________ RESIDENCE: ____________________________________________
CP NO._____________________________________ CP NO.__________________________________________ CP NO.________________________________________________
PURPOSE: __________________________________ PURPOSE: ________________________________________ PURPOSE: _____________________________________________

1. Are you experience the following: (Nakakaranas ka ba ng mga sumusunod? 1. Are you experience the following: (Nakakaranas ka ba ng mga sumusunod? 1. Are you experience the following: (Nakakaranas ka ba ng mga sumusunod?
Most Common Symptoms: Less Common Symptoms: Most Common Symptoms: Less Common Symptoms: Most Common Symptoms: Less Common Symptoms:
Fever Muscle aches and pains Fever Muscle aches and pains Fever Muscle aches and pains
Cough, if checked Dry Cough or with phlegm Sore throat Cough, if checked Dry Cough or with phlegm Sore throat Cough, if checked Dry Cough or with phlegm Sore throat
Tiredness Diarrhea Tiredness Diarrhea Tiredness Diarrhea
Serious Symptoms: Nasal Congestion Serious Symptoms: Nasal Congestion Serious Symptoms: Nasal Congestion
Difficulty in breathing (normal is 12 to 20 breaths/minute) Headache Difficulty in breathing (normal is 12 to 20 breaths/minute) Headache Difficulty in breathing (normal is 12 to 20 breaths/minute) Headache
Chest pain or pressure Loss of taste or smell Chest pain or pressure Loss of taste or smell Chest pain or pressure Loss of taste or smell
Loss of speech or movement Nausea or vomiting Loss of speech or movement Nausea or vomiting Loss of speech or movement Nausea or vomiting

2.Have you worked together or stayed in the same close
environment of a confirmed COVID-19 case?
(May nakasama ka ba o nakatrabahong tao na kumpirmadong
may COVID-19 o may impeksyon ng Corona virus?)
3. Have you any contact with anyone with fever, cough, colds and
sore throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit
sa lalamunan sa nakalipas na dalawang linggo?)
4. Have you travel outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na
labing apat (14) na araw?)
5.Have you travelled to any (Province,HUCs,Barangays) with
CoVid-19 confirmed cases in the past 14 days? (Ikaw ba ay
nagbyahe sa ibang probinsya,HUCs,ICCs o barangay na
mayroong kumpirmadong kaso ng COVID-19 sa nakalipas na
labing apat na araw?)
6. Have you travelled to any other municipality/city apart from your
hometown (home city) in the past 14 days? (Ikaw ay nagbyahe
sa ibapang municipyo/syudad bukod sainyong bayan? Specify
(itala ang lugar:)
Yes No
2.Have you worked together or stayed in the same close environment
of a confirmed COVID-19 case?
(May nakasama ka ba o nakatrabahong tao na kumpirmadong may
COVID-19 o may impeksyon ng Corona virus?)
3. Have you any contact with anyone with fever, cough, colds and sore
throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit sa
lalamunan sa nakalipas na dalawang linggo?)
4. Have you travel outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na labing
apat (14) na araw?)
5.Have you travelled to any (Province,HUCs,Barangays) with CoVid-
19 confirmed cases in the past 14 days? (Ikaw ba ay nagbyahe sa
ibang probinsya,HUCs,ICCs o barangay na mayroong
kumpirmadong kaso ng COVID-19 sa nakalipas na labing apat na
araw?)
6. Have you travelled to any other municipality/city apart from your
hometown (home city) in the past 14 days? (Ikaw ay nagbyahe sa
ibapang municipyo/syudad bukod sainyong bayan? Specify (itala
ang lugar:)
Yes No 2.Have you worked together or stayed in the same close environment of a Yes No
confirmed COVID-19 case?
(May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19
o
may impeksyon ng Corona virus?)
3. Have you any contact with anyone with fever, cough, colds and sore throat in
the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit sa lalamunan sa
nakalipas na dalawang linggo?)
4. Have you travel outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na labing apat (14) na
araw?)
5.Have you travelled to any (Province,HUCs,Barangays) with CoVid-19 confirmed
cases in the past 14 days? (Ikaw ba ay nagbyahe sa ibang
probinsya,HUCs,ICCs o barangay na mayroong kumpirmadong kaso ng
COVID- 19 sa nakalipas na labing apat na araw?)
6. Have you travelled to any other municipality/city apart from your hometown
(home city) in the past 14 days? (Ikaw ay nagbyahe sa ibapang
municipyo/syudad bukod sainyong bayan? Specify (itala ang lugar: )

I hereby authorize Hanawan Elementary School to collect and process the data
indicated herein for the purpose of contact tracing effecting control to COVID-19
transmission. I understand that my personal information is protected by RA 10173
or the Data Privacy Act of 2012 and that this form will be destroyed after 30-days
from the date of accomplishment following the National Archives of the Philippines
Protocol.
I hereby authorize Hanawan Elementary School to collect and process the data
indicated herein for the purpose of contact tracing effecting control to COVID-19
transmission. I understand that my personal information is protected by RA 10173 or
the Data Privacy Act of 2012 and that this form will be destroyed after 30-days from
the date of accomplishment following the National Archives of the Philippines
Protocol.
I hereby authorize Hanawan Elementary School to collect and process the data indicated
herein for the purpose of contact tracing effecting control to COVID-19 transmission. I
understand that my personal information is protected by RA 10173 or the Data Privacy Act
of 2012 and that this form will be destroyed after 30-days from the date of accomplishment
following the National Archives of the Philippines Protocol.

_______________________________
_______________________________ Signature _______________________________
Signature Signature